Date:____________________________

I wish to become a member of the PHYSICS INSTRUCTIONAL RESOURCE ASSOCIATION (PIRA). Enclosed is $10.00 (US funds) which is to cover my membership fee which includes one year's subscription to the PIRA Newsletter with both print and on-line access.

Name: Mr., Mrs., Miss (print): ________________________________________

School Affiliation: ________________________________________

Department: ________________________________________

Address1: ________________________________________

Address2: ________________________________________

City: ____________________ State: ____ Zip + 4____________________

Phone________________________________________

e-mail address: ________________________________________

Home page: http://________________________________________

Title: ________________________________________

I learned of PIRA through ________________________________________

Specific areas of interest: ________________________________________

____ Check here if you wish to participate in PIRA Activities.

____Check here if you would like your information available on the password protected PIRA website. This would include name, work phone, institution and email address.

Make all remittance payable to: PIRA Mail with fees to: Steven Wonnel, Johns Hopkins University,Physics and Astronomy,366 Bloomberg/3400 N.Charles St., Baltimore, MD 21218